A prospective randomized comparison of epidural infusion of fentanyl and intravenous administration of morphine by patient-controlled analgesia after radical retropubic prostatectomy.

In a prospective, randomized study, continuous infusion of epidural fentanyl citrate (group E) was compared with patient-controlled intravenously administered morphine sulfate (group P) for analgesia in 66 men after radical retropubic prostatectomy. Although both methods provided satisfactory analgesia, the mean comfort level scores were lower (that is, greater comfort) in group E than in group P at all observation times. The difference in mean resting comfort level scores between groups E and P was statistically significant (P < or = 0.05) at 9 of the 11 observation times. In addition, significant differences in comfort level scores were noted at 8 of the 11 observation times during deep breathing, 5 of 11 during coughing, and 3 of 9 during ambulation. Maximal and minimal comfort level scores recorded by each patient during the course of the study were significantly lower (that is, less pain) in group E than in group P for all four categories of activity. The percentage of patients who reported no pain was significantly higher in group E than in group P at 9 of 11 observation times during resting and 5 of 11 observation times during deep breathing. No significant differences were noted in side effect profiles or duration of hospital stay. In summary, when two effective methods of analgesia used after radical retropubic prostatectomy were compared prospectively, patients who received epidural infusion of fentanyl were more comfortable than those with patient-controlled intravenous administration of morphine, as evidenced by lower mean, maximal, and minimal comfort level scores and a greater proportion of patients with complete relief of pain.

Epidural analgesia shortens postoperative ileus after ileal pouch-anal canal anastomosis.

PURPOSE: A retrospective study was conducted to determine whether epidural analgesia would speed recovery from postoperative ileus in patients undergoing ileal pouch-anal canal anastomosis. METHODS: Among 85 patients who underwent proctocolectomy with ileal pouch-anal canal anastomosis at the Mayo Medical Center between January 1, 1991 and October 31, 1992, 44 were treated for postoperative pain with continuous infusion of epidural fentanyl citrate supplemented by intravenous morphine on request, while 41 controls were given only systemic morphine sulfate as needed. RESULTS: The patients in the two groups were matched and similar with regard to preoperative and operative risk factors and postoperative morbidity. No operative mortality occurred. Epidural fentanyl analgesia resulted in less need for nasogastric suction and intravenous fluids, more rapid discharge of fecal content, more rapid return to oral intake, and shorter hospitalization. CONCLUSION: Epidural analgesia with fentanyl citrate shortened postoperative ileus after proctocolectomy and ileal pouch-anal canal anastomosis.

Carotid endarterectomy: results, complications, and monitoring techniques.

A system of grouping patients according to preoperative evaluation of risk of carotid endaterectomy is presented. The primary complications of this surgical procedure were myocardial infarction and residual mild to severe neurologic deficit. Neurologically stable patients without medical or angiographically determined risk factors (group 1) have a risk of 1%. Neurologically stable patients without medical risk but with angiographically determined risks (group 2) have a risk of 2%. Neurologically stable patients with significant medical illness and with or without angiographically determined risks (group 3) have a risk of 7%, primarily related to cardiac disease. Neurologically unstable patients (group 4) have a 6% risk for a neurologic deficit. Current monitoring techniques using continuous electroencephalograms, cerebral blood flow measurements, and arterial stump pressure are considered. The prevention and management of complications are presented in some detail.

A simple approach to interrater agreement.

We have described a simple method for computing a measure of interrater agreement or reliability. This method depends on an experimental design that uses a consensus rating as well as individual ratings. The computations required are counting and percentages; the overall agreement index uses a simple weighting average.

The role of operations research and systems analysis in holding down the costs of hospitals and clinics.

In the past, medical care facilities have concentrated primarily on professional clinical evaluation. With the cost of treatment rising rapidly, it is becoming increasingly important to critically review and analyze our delivery systems so that scarce resources can be used optimally. In this paper the applications of operations research (O.R.) and systems analysis techniques that have been employed successfully in private industry are explored to find ways to improve clinical operations and hold costs down.

Brachial plexus neuropathy following attempt at subclavian vein catheterization. Case report.

BACKGROUND AND OBJECTIVES: The subclavian vein is often used for placement of central venous catheters, and the possibility exists of nerve injury as a complication of the procedure. METHODS: A 58-year-old woman undergoing subclavian central catheter placement sustained a brachial plexus injury. A review of the English-language literature revealed no reports of brachial plexus injury during placement of a subclavian central catheter, although three reports were found in the non-English-language literature. RESULTS: The anatomic relationship of the subclavian artery, vein, and brachial plexus at the supraclavicular triangle is described, and suggestions are given as to how to avoid this problem. CONCLUSIONS: Brachial plexus injury can occur with placement of subclavian central catheters, but proper technique should minimize this complication.

A systems analysis approach to planned change in a clinical psychiatric program.

In health car facilities, systems studies are commonly conducted as ivory-tower operations with minimal impact and little practical result. A real-life case study was presented to demonstrate how it can be used effectively in a collaborative manner to implement constructive change. Systems Analysis techniques were succe-sfully used with the staff of a psychiatric ward to plan for a satellite outpatient treatment program. The focus was on collaboration to help the ward to obtain objective information for decisions concerning the need for changes in their existing system.

Anesthesia for transsphenoidal surgery of the hypophyseal region.

For pituitary surgery--by either the transcranial or the transsphenoidal approach--anesthetic management conforms to the general principles of neuroanesthesia as discussed in texts and review articles. In addition, the endocrine functions and the anatomic situation of the pituitary gland must be considered. Preoperative and perioperative evaluation of the patient's endocrine status and appropriate therapeutic measures are important. Preservation of neurohypophyseal function and, frequently, of adequate adenohypophyseal function is an advantage of the transsphenoidal approach to the sella. Potential problems with the transsphenoidal technic include damage to suprasellar and parasellar structures and harzards associated with intraoperative or postoperative bleeding. Anesthetic aspects peculiar to the transsphenoidal approach include positioning of the patient, surgical use of solutions containing epinephrine and topical cocaine, intraoperative air studies, and management of emergence. Anesthesia for the transsphenoidal approach to the sella is discussed on the basis of our experience with 148 surgical procedures in 142 patients.

ASA monitoring standards and magnetic resonance imaging.

Some patients, often because of age or altered mental state, require general anesthesia or monitored anesthesia care and sedation if adequate magnetic resonance imaging (MRI) is to be accomplished. This study evaluated whether patients can be monitored during MRI with 1.5-tesla scanners in a manner which complies with ASA monitoring standards without causing degradation of image quality. Ten volunteers were scanned in the MRI without sedation. Monitors meeting ASA standards were placed and electronic artifact produced by the magnetic resonance (MR) scanner was evaluated, after which two scans of the head and two of the chest were performed. One of each pair of scans was obtained with the monitors functioning and one with them turned off. Four radiologists, blinded as to whether the monitors were turned on or off, independently evaluated the 20 pairs of scans. Differences in diagnostic quality and image degradation between the scans were evaluated and scores assigned. All monitors functioned appropriately during the scans, with the exception of the electrocardiogram (ECG) which was grossly distorted to the extent that only ventricular rate could be evaluated. None of the head or body scans was nondiagnostic; however, images with the monitors off were of better quality overall than with them on. Two types of noise were generated and are described. During the head scans, three of seven monitoring combinations caused degradation of the images, while four were judged clinically adequate. During the body scans, two of six monitoring combinations created noticeable noise, while four introduced no significant noise. Ungated cardiac scans were nondiagnostic.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving patient care through measurement: goal importance and achievement scaling.

Sophisticated treatment record keeping requires something more than a focus on problems. An emphasis on positive aspects of treatment, i.e., on goals may be more appropriate for certain patients or for certain types of treatment or at specific stages of an illness. Unfortunately, currently available methods of quantifying goal importance and achievement are not entirely satisfactory for general everday use. GIA is proposed as a simple procedure for quantifying judgments of the importance of a treatment goal, of the extent to which that goal is achieved and of determining the social value of what treatment has accomplished. GIA ratings have considerable potential for improving patient care through measurement.

Adopting new models for continuity of care: the ward as mini-mental-health-center.

Several years ago the staff of a traditional psychiatric ward in a Veterans Administration hospital began trying to provide continual care for their former inpatients after they left the hospital. Nursing assistants conducted basic-skills groups and other groups in board-and-care homes; staff members made themselves available to former inpatients and theri families, roommates, or board-and-care sponsors through a 24-hour telephone service and home visits; and a day-care program and follow-up groups for the ward's outpatients were set up. Later the staff establiched additional day-care and follow-up programs in a downtown satellite unit. In a recent three month period, patients made a total of 4488 visits to the satellite and hospital programs. The preceding paper discusses some of the theoretical considerations on which this program and other alternatives to traditional care are based.

Time required and success rate of percutaneous right atrial catheterization: description of a technique.

The use of an intracardiac catheter is considered useful in the diagnosis of air embolism during surgical operations. Under electrocardiographic (ECG) control a right atrial catheter was placed through the right antecubital (basilic) vein in 200 patients undergoing posterior fossa or cervical operations in the sitting position. The overall success rate for this technique was 97 per cent. Half were successfully placed within five minutes, and 92 per cent within 15 minutes.

Approaches to reliability in a clinical simulation study.

Discusses the reliability of measurements made by 48 raters who used the Problem Dysfunction Rating Scale (PDRS) under simulated routine clinical record-keeping conditions. Ten- to 15-minute videotape interviews of two simulated patients with predefined problems were shown to a multidisciplinary psychiatric hospital staff of varying educational background and clinical experience. These raters were given only brief instructions and no training in the use of the PDRS. Statistical analysis included application of the usual, traditional test and retest variation studies and used variance components and comparison to random rating models. A random contrast of rater agreement was found to index most realistically reliability in instances such as this, in which a large number of raters rate a small number of items. There was greater intrarater consistency than interrater agreement, and it was concluded that when reasonably adequate information was available the degree of dysfunction due to patients' problems could be rated on the PDRS with a useful degree of consistency by untrained raters.

Correlation of regional cerebral blood flow (rCBF) with EEG changes during isoflurane anesthesia for carotid endarterectomy: critical rCBF.

A prospective evaluation of regional cerebral blood flow (rCBF) (ipsilateral middle cerebral artery distribution) was determined using a 133Xe clearance technique in 31 ASA P.S. II-III patients anesthetized with isoflurane-50% N2O in O2 for carotid endarterectomy. Each patient was monitored with 16-channel EEG throughout anesthesia and surgery. Critical rCBF was defined as that flow below which EEG signs of ischemia occurred. Critical rCBF (T1/2 method of analysis) was less than 10 ml X 100 g-1 X min-1 (mean +/- SE 5.9 +/- 1.2) in the six patients in whom transient EEG changes occurred at the time of temporary surgical carotid artery occlusion. No EEG changes occurred with occlusion in the other 25 patients; mean (+/- SE) occlusion rCBF in this group was 18.9 +/- 1.3 ml X 100 g-1 X min-1 (P less than 0.001). Preocclusion flows were not significantly different in the two groups. Critical rCBF during isoflurane anesthesia was less than that previously determined during halothane anesthesia (18-20 ml X 100 g-1 X min-1), and is compatible with the effects of isoflurane on CMRO2 and CBF.

The risk-benefit ratio of intraoperative shunting during carotid endarterectomy. Relevancy to operative and postoperative results and complications.

The relative risk of shunting versus not shunting during carotid endarterectomy was analyzed retrospectively in 1935 cases undergoing carotid endarterectomy for carotid ulcerative stenosis. The need for shunting was based on a correlation between electroencephalographic changes and a fall in cerebral blood flow below the critical level required for adequate perfusion during the period of carotid occlusion. Patients were divided into four risk categories for surgery, based on medical and neurological risks and angiographic findings. Shunts were required in 30% of the low risk group and 56% of the high risk group. Based on the severity of reductions of cerebral blood flow during the period of carotid occlusion it is concluded that 12% of all patients would have sustained a major deficit, 15% a minor or transient deficit, and 20% a transient deficit without shunting. The risk of shunting 792 cases in this series was 0.5%. Overall minor morbidity, major morbidity, and mortality each approximated 1% in this series.

Amine sulfate formation in the central nervous system.

The sulfates of norepinephrine, dopamine (DA), and serotonin (5-hydroxytryptamine [5HT]) are present in the cerebrospinal fluid (CSF) of laboratory animals and humans. The amounts of sulfated amines in human CSF always greatly exceed the amounts of the free amines. The enzyme responsible for sulfation, phenol sulfotransferase (PST) (EC 2.8.2.1), has been detected in the brain tissue of several species, including humans. PST in the human brain has a high affinity for the amines but it is a low-capacity enzyme. Accordingly, sulfation appears to be of greater significance in the economy of the amines under quiescent conditions than during conditions of increased release of transmitter. Recent evidence suggests that a fraction of the conjugated amines in CSF enters from plasma because in the African green monkey, DA sulfate and 5HT sulfate cross the blood-CSF barrier after i.v. injection. In addition, in humans there are no increases in the concentration of amine sulfates from lumbar to ventricular CSF that would also be compatible with a partly peripheral origin for the amine sulfates. However, it appears that at least a portion of the amine sulfates in CSF originate in the central nervous system because the ratios of [CSF amine sulfates]/[plasma sulfates] are never as high after i.v. injection as under basal conditions.

Isoflurane and cerebrospinal fluid pressure in neurosurgical patients.

The effect of isoflurane on cerebrospinal fluid pressure (CSFP) was determined in 20 patients undergoing craniotomy for intracranial supratentorial neoplasm or hepatoma. In 15 of these patients, following endotracheal intubation, hyperventilation sufficient to result in PaCO2 25-30 torr was begun simultaneously with the introduction of 1 per cent isoflurane. In the remaining five patients ventilation was equivalent, but normocapnia was maintained by adding CO2 to the inspired gases. In the hypocapnic patients CSFPs did not increase above awake values (range 5-45 torr) following isoflurane administration. In the normocapnic patients (CSFPs consistently increased. In three of these five patients the increases were precipitous, but were corrected rapidly by establishment of hypocapnia. The authors conclude that the known cerebral vasodilator properties of isoflurance can be countered effectively by hypocapnia. Furthermore, unlike the situation with halothane, it is not necessary to establish hypocapnia prior to introducing isoflurane in order to avoid CSFP increases.